Provider Demographics
NPI:1396520466
Name:CLARK, REBECCA SUE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-2919
Mailing Address - Country:US
Mailing Address - Phone:406-560-3247
Mailing Address - Fax:
Practice Address - Street 1:401 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-1999
Practice Address - Country:US
Practice Address - Phone:406-563-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-103949163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse